A study protocol for improving the delivery of acute kidney replacement therapy (KRT) to critically ill patients in Alberta - DIALYZING WISELY.

BACKGROUND: Acute kidney replacement therapy (KRT) is delivered to acutely ill patients to support organ function and life in the Intensive Care Unit (ICU). Implementing standardized acute KRT pathways can ensure its safe and effective management. At present, there is no standardized approach to the management of acute KRT in Alberta ICUs. METHODS: Dialyzing Wisely is a registry embedded, stepped-wedge, interrupted time-series evaluation of the implementation of a standardized, stakeholder-informed, and evidence-based acute KRT pathway into Alberta ICUs. The acute KRT pathway will consist of two distinct phases. First, we will implement routine monitoring of evidence-informed key performance indicators (KPIs) of acute KRT. Second, we will provide prescriber and program reports for acute KRT initiation patterns. After the implementation of both phases of the pathway, we will evaluate acute KRT performance quarterly and implement a customized suite of interventions aimed at improving performance. We will compare this with baseline and evaluate iterative post implementation effects of the care pathway. DISCUSSION: Dialyzing Wisely will implement, monitor, and report a suite of KPIs of acute KRT, coupled with a care pathway that will transform the quality of acute KRT across ICUs in Alberta. This program will provide a framework for scaling evidence-informed approaches to monitoring and management of acute KRT in other jurisdictions. We anticipate improvements in acute KRT performance, decreased healthcare system costs and improved patient quality of life by decreasing patient dependence on maintenance dialysis. TRIAL REGISTRATION: Clinicaltrials.gov , NCT05186636. Registered 11, January, 2022.

Return on Investment in Endovascular Care: The Case of Endovascular Reperfusion Alberta.

OBJECTIVE: We examined the return on investment (ROI) from the Endovascular Reperfusion Alberta (ERA) project, a provincially funded population-wide strategy to improve access to endovascular therapy (EVT), to inform policy regarding sustainability. METHODS: We calculated net benefit (NB) as benefit minus cost and ROI as benefit divided by cost. Patients treated with EVT and their controls were identified from the ESCAPE trial. Using the provincial administrative databases, their health services utilization (HSU), including inpatient, outpatient, physician, long-term care services, and prescription drugs, were compared. This benefit was then extrapolated to the number of patients receiving EVT increased in 2018 and 2019 by the ERA implementation. We used three time horizons, including short (90 days), medium (1 year), and long-term (5 years). RESULTS: EVT was associated with a reduced gross HSU cost for all the three time horizons. Given the total costs of ERA were $2.04 million in 2018 ($11,860/patient) and $3.73 million in 2019 ($17,070/patient), NB per patient in 2018 (2019) was estimated at -$7,313 (-$12,524), $54,592 ($49,381), and $47,070 ($41,859) for short, medium, and long-term time horizons, respectively. Total NB for the province in 2018 (2019) were -$1.26 (-$2.74), $9.40 ($10.78), and $8.11 ($9.14) million; ROI ratios were 0.4 (0.3), 5.6 (3.9) and 5.0 (3.5). Probabilities of ERA being cost saving were 39% (31%), 97% (96%), and 94% (91%), for short, medium, and long-term time horizons, respectively. CONCLUSION: The ERA program was cost saving in the medium and long-term time horizons. Results emphasized the importance of considering a broad range of HSU and long-term impact to capture the full ROI.

Provincial Door-to-Needle Improvement Initiative Results in Improved Patient Outcomes Across an Entire Population.

BACKGROUND AND PURPOSE: Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes. METHODS: A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback. RESULTS: Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51-93) to 39.0 minutes (interquartile range, 27-58) for patients treated per guideline (P<0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% (P<0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3-55.8) to 53.6 days (interquartile range, 36.8-64.6) (P=0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% (P=0.0990). CONCLUSIONS: The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.

Improving Door-to-needle Times in the Treatment of Acute Ischemic Stroke Across a Canadian Province: Methodology.

BACKGROUND: Alteplase is a proven medical treatment for acute ischemic stroke; however, the effectiveness of this treatment is highly time dependent. Therefore, it is imperative that hospitals treat acute ischemic stroke patients as quickly as possible. The measure, door-to-needle time, is the time from hospital arrival to when alteplase administration begins. OBJECTIVE: The goal in the Canadian province of Alberta was to reduce the door-to-needle time to a median of 30 minutes and to increase the percent of patients treated within 60 minutes to 90%. OVERVIEW OF METHODOLOGY: A modified version of Institute for Healthcare Improvement Breakthrough Series Collaborative was used. All stroke centers self-enrolled into the collaborative after initial contact, and sites created interdisciplinary teams to participate in the Collaborative. Leadership and faculty were highly experienced in quality improvement and acute stroke. There were 3 daylong face-to-face learning sessions that were attended by enrolled teams, which included presentation about the evidence, site presentations to promote cross-site learning, and time to plan changes with their teams. The sites were also supported by site visits, webinars, and data feedback.

Cost-effectiveness of home blood pressure telemonitoring and case management in the secondary prevention of cerebrovascular disease in Canada.

Home blood pressure (BP) telemonitoring and pharmacist case management reduce BP, but cost-effectiveness assessments are mixed. We examined the incremental cost-effectiveness of this intervention vs usual care in Canadians with cerebrovascular disease. A Markov decision model cost-utility analysis examining community-residing, high-risk patients with a recent nondisabling cerebrovascular event was created. A lifetime time horizon and health care payer perspective were used. Achieved BP, future cardiovascular risks, and attendant consequences on quality-adjusted life years and Canadian dollar costs were modeled. BP telemonitoring was assumed to occur for 3 months, then quarterly. Life tables were used to determine overall mortality, adjusted by cardiovascular disease mortality. Relative efficacies of intervention-associated BP lowering, resource use, and costs were obtained from Canadian published literature. Reduction in systolic BP of 9.7 mmHg was used in the base case; subsequently, robust sensitivity analyses were conducted. The results showed that, over the lifetime horizon, telemonitoring with case management led to net health care savings of $1929 Canadian and increased per-patient QALYs by 0.83. These findings were robust to sensitivity analysis, with the intervention remaining dominant or highly cost-effective. Increasing telemonitoring costs by 50% still resulted in the intervention being dominant; if the costs of telemonitoring plus case management were 2-3 times base case cost, incremental cost-effectiveness was $1200-$4700 per quality-adjusted life year gained. In conclusion, home BP telemonitoring and pharmacist case management poststroke lowered costs and improved QALYs. Strategies and funding for broad implementation of this dominant strategy should be implemented.

Reducing Door-to-Needle Times for Ischaemic Stroke to a Median of 30 Minutes at a Community Hospital.

BACKGROUND: Alteplase is an effective treatment for ischaemic stroke patients, and it is widely available at all primary stroke centres. The effectiveness of alteplase is highly time-dependent. Large tertiary centres have reported significant improvements in their door-to-needle (DTN) times. However, these same improvements have not been reported at community hospitals. METHODS: Red Deer Regional Hospital Centre (RDRHC) is a community hospital of 370 beds that serves approximately 150,000 people in their acute stroke catchment area. The RDRHC participated in a provincial DTN improvement initiative, and implemented a streamlined algorithm for the treatment of stroke patients. During this intervention period, they implemented the following changes: early alert of an incoming acute stroke patient to the neurologist and care team, meeting the patient immediately upon arrival, parallel work processes, keeping the patient on the Emergency Medical Service stretcher to the CT scanner, and administering alteplase in the imaging area. Door-to-needle data were collected from July 2007 to December 2017. RESULTS: A total of 289 patients were treated from July 2007 to December 2017. In the pre-intervention period, 165 patients received alteplase and the median DTN time was 77 minutes [interquartile range (IQR): 60-103 minutes]; in the post-intervention period, 104 patients received alteplase and the median DTN time was 30 minutes (IQR: 22-42 minutes) (p < 0.001). The annual number of patients that received alteplase increased from 9 to 29 in the pre-intervention period to annual numbers of 41 to 63 patients in the post-intervention period. CONCLUSION: Community hospitals staffed with community neurologists can achieve median DTN times of 30 minutes or less.

CONTEXTE: L'altéplase est un traitement efficace dans le cas de patients victimes d'AVC ischémiques et demeure largement disponible dans les centres de soins de niveau primaire dédiés aux AVC. Cela dit, son efficacité dépend fortement des délais en fonction desquels on peut l'administrer. À cet égard, les centres de soins de niveau tertiaire ont fait état d'importantes améliorations en ce qui regarde leurs délais entre l'arrivée de patients et l'injection d'un traitement thrombolytique. Toutefois, il semble que de telles améliorations n'ont pas été signalées dans les hôpitaux communautaires. MÉTHODES: Le Red Deer Regional Hospital Centre (RDRHC) est un hôpital communautaire de 370 lits qui dessert approximativement 150 000 personnes dans sa zone d'attraction. Cet hôpital a participé à une initiative provinciale de réduction des délais mentionnés ci-dessus. Pour ce faire, il a mis au point un algorithme simplifié en vue du traitement de patients victimes d'AVC. Au cours de cette période d'intervention, les mesures de changement suivantes ont donc été adoptées : des alertes précoces transmises à un neurologue et aux équipes soignantes au moment de l'admission de patients victimes d'AVC aigus ; des rencontres immédiates avec les patients, et ce, dès leur arrivée à l'hôpital ; des processus de travail menés de façon parallèle ; le maintien des patients dans une civière d'ambulance jusqu'à temps qu'on puisse les conduire à un tomodensitomètre ; enfin, le fait d'administrer l'altéplase en fonction de la zone atteinte révélée par imagerie. Soulignons enfin que nos données en matière de réduction des délais ont été collectées de juillet 2007 à décembre 2017. RÉSULTATS: Au total, 289 patients ont été traités durant cette période. Au cours de la période antérieure à l'initiative évoquée précédemment, 165 patients ont bénéficié d'un traitement à l'altéplase ; les délais médians entre l'arrivée des patients et l'injection de ce médicament thrombolytique étaient alors de 77 minutes (EI : 60-103 minutes). Une fois mise en place l'initiative de réduction des délais, 104 patients ont reçu un traitement à l'altéplase ; cette fois, les délais médians du RDRHC étaient de 30 minutes (EI : 22-42 minutes ; p < 0,001). Fait à noter, le nombre annuel de patients ayant bénéficié de l'altéplase est passé de 9 à 29 durant la période pré-initiative et de 41 à 63 lors de la période post-initiative. CONCLUSION: Dans le cas des hôpitaux communautaires disposant de neurologues réguliers, il est possible de parvenir à des délais de 30 minutes ou moins entre l'arrivée de patients et l'injection d'un traitement thrombolytique.

Evaluating clinical reason and rationale for not delivering reperfusion therapy in ST elevation myocardial infarction patients: Insights from a comprehensive cohort.

BACKGROUND: In ST elevation myocardial infarction (STEMI), reperfusion therapy is lifesaving but is not delivered in approximately one quarter of patients. To address this care gap, we reviewed all STEMI patients that did not receive reperfusion to identify patient characteristics, in-hospital outcomes and the clinical reason or rationale for withholding reperfusion therapy. METHODS: A prospective chart review identified a consecutive cohort of STEMI patients over one-year within a defined health care region with independent data abstraction. Subsequently a trained nurse completed retrospective chart review and categorized patients by rationale for failure to receive reperfusion. RESULTS: Of 745 STEMI patients, 181 (24.3%) did not receive reperfusion. Compared to those receiving reperfusion, they were older (67.5 vs. 58.0years, p=0.001) with more comorbidities and higher in-hospital mortality (15.5% vs. 3.5% p=<0.0001). After excluding 35 patients (unavailable data) there were 146 STEMI patients for qualitative determination. Patient delay greater than 12hours from symptom onset accounted for the majority of patients (56/146, 38.4%). In 19.9% (29/146), conservative medical management with documented rationale occurred. Following angiography, primary PCI was attempted but was unsuccessful or no culprit lesion identified in 19.2% (28/146). The diagnosis of STEMI was missed or no rationale for failure to deliver therapy identified in 8.2% (12/146). Death prior to planned reperfusion occurred in 8 (8/146, 5.5%). CONCLUSIONS: Legitimate rationale exists for the majority of STEMI patients not receiving reperfusion. Ultimately, only 1.6% (12/745) of consecutive STEMI patients failed to receive reperfusion without documented rationale or due to missed diagnosis.